BACKGROUND: Moral injury is prevalent among health care professionals, especially nurses. It can have negative personal consequences for clinicians, and indirectly impact the quality of patient care. Although nurses around the world experienced moral injury during the pandemic, it will continue to be a professional challenge. Thus, this study aimed to determine the psychometric properties of a scale measuring moral injury translated into Spanish.
METHODS: A methodological study with a cross-sectional approach was conducted. After translating the Moral Injury Symptom Scale for Healthcare Professionals (MISS-HP) into Peruvian Spanish (MISS-HP-S) using International Test Commission methods, data were collected using online survey methods from a sample of 720 Peruvian nurses. Analytical methods included exploratory and confirmatory factor analysis, and invariance by age were examined. The corrected homogeneity index, ordinal alpha, and McDonald\'s omega allowed the evaluation of internal reliability.
RESULTS: Findings from this sample of nurses who were mostly female (92%), from coastal Peru (57%), and averaged 39 (± 11) years of age, provided support for the validity and reliability of the MISS-HP-S. Structural validity was endorsed by findings indicating consistent factorial structure and adequate invariance among different age groups. In this study, three factors were observed: guilt/shame, condemnation, and spiritual strength. Internal consistency values included an ordinal alpha of 0.795 and McDonald\'s omega of 0.835.
CONCLUSIONS: These findings differ from those reported from previous studies in other cultural contexts, suggesting the influence of cultural and sample-specific factors in the perception of moral injury among Peruvian nurses. Because this evidence supports the validity of the MISS-HP-S, it can be used in professional practice and in future research to identify and address situations that contribute to nurse moral injury.

Nurses around the globe have been impacted psychologically and emotionally during and after the COVID-19 pandemic. The purpose of this study was to describe nurses\' perspectives on the concepts of compassion fatigue, second victimhood, burnout, and moral injury. Eight nurses were interviewed either individually or in groups of two. Data were analyzed using conventional content analysis. The following themes were identified: waves of compassion fatigue, traumatization within second victimhood, never the same after chronic burnout, moral injury: nurses couldn\'t do their best, and connections across concepts. Results showed nurses were most familiar with burnout and compassion fatigue, which remain chronic struggles. Second victimhood and moral injury were more distinct experiences related to traumatic or morally distressing events and likely contributed to experiencing burnout or compassion fatigue. Nurses\' suffering heightened during the COVID-19 pandemic and remains prominent three years later. Future research and interventions are urgently needed globally to reduce workplace stressors and promote nurse well-being.

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Healthcare social workers (HSWs) in the United States are integral to interdisciplinary teams and health services. HSWs have a unique role in healthcare, as they care for their patients\' psychosocial needs, through case management and clinical services. There is a gap in understanding how HSWs are impacted by their healthcare work. This study aims to understand the experience of moral injury, a marker of well-being, amongst HSWs in one state in the United States. Moral injury is the moral transgression (or boundary breaking) by oneself or someone in a position of power in high stakes situations and the negative outcomes of those experiences. Using a qualitative approach, semi-structured interviews were conducted with 24 HSWs in August of 2022. Thematic analysis was used to understand the lived experience of moral injury for HSWs. Three themes emerged: 1) HSWs\' definition and examples of moral injury; 2) HSWs situated in the \"in-between\" of policy and practice; and 3) upholding social work values within the medical model. These findings impact healthcare practice and policy, in delineating what falls within the bounds of social work, changing the workflow of health services, and creating further opportunities for interdisciplinary training, well-being initiatives, and systems-level changes. The findings from this work highlight the importance of understanding the moral impact of healthcare work on social workers, which should be further examined in depth not only amongst HSWs but also across the healthcare workforce.

BACKGROUND: Staffing shortages across the healthcare sector pose a threat to the continuity of the Canadian healthcare system in the post-COVID-19 pandemic era. We sought to understand factors associated with turnover intention as well as Canadian healthcare providers\' (HCPs) perspectives and experiences with turnover intention as related to both organizational and professional turnover.
METHODS: A convergent questionnaire mixed-methods design was employed. Descriptive statistics and ordinal logistic regressions were used to analyze quantitative data and ascertain factors associated with turnover intention. Thematic analysis was used to analyze qualitative open-field textbox data and understand HCPs\' perspectives and experiences with turnover intention.
RESULTS: Quantitative analyses revealed that 78.6% of HCPs surveyed (N = 398) reported at least a 25% turnover likelihood regarding their organization, with 67.5% reporting at least a 25% turnover likelihood regarding their profession. Whereas regression models revealed the significant impact of years worked, burnout, and organizational support on turnover likelihood for organizations, age, sex, burnout, and organizational support contributed to the likelihood of leaving a profession. Patterns of meaning drawn from participants\' qualitative responses were organized according to the following four themes: (1) Content to stay, (2) Drowning and no one cares, (3) Moral stressors, and (4) Wrestling with the costs and benefits.
CONCLUSIONS: Many HCPs described weighing the costs and benefits of leaving their organization or profession during the COVID-19 pandemic. Although challenging working conditions, moral stressors, and burnout may play a significant role in HCPs\' experiences of turnover intention, there is ample room to intervene with organizational support.

Exposure to potentially morally injurious events (PMIEs) among combat veterans has been acknowledged as a significant stressful combat event that may lead to various mental health problems, including depression and moral injury (MI), outcomes of shame and guilt. Recent studies have examined both risk and protective factors that can contribute to PMIEs and their consequences. However, while the general level of one\'s moral judgment is a logical contributor to moral injuries, it has yet to be examined empirically. In the current study, we examined the unique impact of moral judgment levels on the experience of PMIEs among combat veterans. We also examined the moderating role of moral judgment in the relationship between PMIEs and MI outcomes and depressive symptoms. A volunteer sample of 70 male Israeli combat veterans completed self-report questionnaires and a moral judgment task in a cross-sectional design study. Our findings indicate that moral judgment contributed to higher levels of perceiving others\' actions as transgressive (PMIE-Other), above and beyond combat exposure. Moreover, we found that moral judgment has a moderating role in the link between PMIEs and their negative outcomes: Among veterans with higher levels of moral judgment, the association between PMIEs and their expressions was stronger than for those with lower levels of moral judgment. Our finding highlights the unique contribution of moral judgment level to PMIEs and their mental health consequences. It can be cautiously suggested that moral judgment should be viewed as a pre-recruitment risk factor that can help identify those at greater risk for mental health problems following exposure to PMIEs.

UNASSIGNED: Moral injury is a potentially debilitating outcome of exposure to events involving transgressions against an individual\'s moral code. It is often observed in the context of PTSD; however, treatments that do not differentiate the two are often ineffective for moral injury, suggesting different mechanisms contribute to the conditions. The most widely accepted model of moral injury proposes an important role for self-discrepancy processes in generating and maintaining event-related distress, but this has yet to be examined.
UNASSIGNED: This study recruited 172 adults online who had been exposed to a potentially morally injurious event in the previous 5 years. Participants completed measures of event-related distress, PTSD, depression, and anxiety, as well as a self-discrepancy task involving subjective representations of their ideal, ought, and feared selves.
UNASSIGNED: Multiple regression analyses found a small but significant relationship between self-discrepancy and event-related distress, with higher levels of ought self-discrepancy independently predicting higher event-related distress scores.
UNASSIGNED: This study provides the first empirical evidence of the relationship between self-discrepancy and moral injury. We identified the ought self as a domain of self-discrepancy salient to moral injury, further differentiating moral injury from PTSD.

With about 1200 individuals murdered, the massacre of October 7th was one of the deadliest terrorist attacks in modern history. The mental health consequences of terrorist attacks have been documented. However, little is known of the impact of the potentially morally injurious experience (PMIE) of betrayal--in which individuals feel betrayed by leaders they once trusted--on levels of psychological burden in the aftermath of such an attack. In this national prospective cohort study, we examined to what extent the PMIE of betrayal exacerbates the risk for posttraumatic stress disorder (PTSD) and depression in the wake of the October 7th terrorist attack. A representative sample of 710 Israeli adults (362 female, 51.1%), Jews (557, 79.9%) and Arabs (153, 20.1%), aged 18-85 (M = 41.01, SD = 13.72) completed validated self-report questionnaires assessing PTSD, depression, and PMIE-betrayal at two timepoints: T1, in August 2023 (6-7 weeks before the attack) and T2, in November 2023 (5-6 weeks after the attack). In two hierarchical logistic regressions, we found that experience of PMIE-betrayal predicted diagnoses of both PTSD (OR 1.92, 95% CI 1.26-2.92) and depression (OR 2.03, 95% CI 1.37-3.01) at T2, beyond probable PTSD/depression at T1 and demographic and trauma-related variables. Moreover, in two repeated-measure analyses predicting PTSD/depression symptoms, we found significant interactions between PTSD/depression trajectories and PMIE-betrayal, meaning that the increase of PTSD/depression symptoms was significantly higher among participants experiencing betrayal in the context of the attack. Our study highlights the impact of PMIE of betrayal on the dramatic increase in psychopathology following the October 7th terror attack on Israel\'s population. Clinicians treating individuals coping with PTSD and depression should attend to their patients\' possible exposure to betrayal following the attack. Moreover, national leaders and policymakers should take significant steps to repair the public\'s betrayal experience.

BACKGROUND: While it is already known that potentially morally injurious events (PMIEs) have a deleterious effect on veterans, little is known about the changes in PMIEs subjective appraisals over time, as well as its contribution to changes in psychiatric symptoms. In the current study, we longitudinally assessed subjective appraisals of PMIEs experienced during combat military service and their associations with posttraumatic stress symptoms (PTSS) among recently discharged combat veterans.
METHODS: Participants were 374 veterans who participated in a one-year longitudinal study with three measurement points: T1-one month before discharge from army service, and then again six months and twelve months following discharge (T2 and T3, respectively).
RESULTS: Latent Growth Mixture Modeling (LGMM) indicated heterogenic patterns of changes in PMIEs across measurements. The \'resilient\' (low and stable PMIEs) trajectory best represented PMIE, followed by \'recovery\' and \'chronic\' fluctuating trajectories. Moreover, the \'resilient\' PMIEs trajectory was found to be consistently associated with lower PTSS scores compared to \'chronic\' or \'worsening\' trajectories.
CONCLUSIONS: Our findings are the first to identify longitudinal trajectories of PMIEs subjective appraisals and to provide evidence of their association with PTSS, which might serve as potential assessment and intervention targets among recently discharged traumatized veterans.

This article examines how U.S. immigration law extends into the health care safety net, enacting medical legal violence that diminishes noncitizens\' health chances and transforms clinical practices. Drawing on interviews with health care workers in three U.S. states from 2015 to 2020, I ask how federal citizenship-based exclusions within an already stratified health care system shape the clinical trajectories of noncitizens in safety-net institutions. Focusing specifically on cancer care, I find that increasingly anti-immigrant federal policies often reshape clinical practices toward noncitizens with a complex, life-threatening condition as they approach a \"specialty care cliff\" by (1) creating time penalties that keep many noncitizens in a protracted state of injury and (2) deterring noncitizens from seeking care through threats of immigration enforcement. Through these processes, medical legal violence also creates the potential for moral injury among health care workers, who must adapt clinical practices in response to socio-legal boundaries of belonging.